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Hassan, O A., Affognon, H., Rocklöv, J., Mburu, P., Sang, R. et al. (2017)The One Health approach to identify knowledge, attitudes and practices that affect communityinvolvement in the control of Rift Valley fever outbreaks.PLoS Neglected Tropical Diseases, 11(2): e0005383https://doi.org/10.1371/journal.pntd.0005383

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RESEARCH ARTICLE

The One Health approach to identify

knowledge, attitudes and practices that affect

community involvement in the control of Rift

Valley fever outbreaks

Osama Ahmed Hassan1,2*, Hippolyte Affognon3,4, Joacim Rocklov5, Peter Mburu3,

Rosemary Sang3, Clas Ahlm6, Magnus Evander1

1 UmeåUniversity, Clinical Microbiology, Virology, Umeå, Sweden, 2 Public Health Institute, Khartoum,

Sudan, 3 International Centre of Insect Physiology and Ecology, Nairobi, Kenya, 4 International Crops

Research Institute for the Semi-Arid Tropics (ICRISAT), Bamako, Mali, 5 UmeåUniversity, Public Health and

Clinical Medicine, Epidemiology and Global Health and UmeåCentre for Global Health Research, Umeå,

Sweden, 6 UmeåUniversity, Clinical Microbiology, Infectious Diseases, Umeå, Sweden

* osama.a.hassan@umu.se

Abstract

Rift Valley fever (RVF) is a viral mosquito-borne disease with the potential for global expan-

sion, causes hemorrhagic fever, and has a high case fatality rate in young animals and in

humans.

Using a cross-sectional community-based study design, we investigated the knowledge,

attitudes and practices of people living in small village in Sudan with respect to RVF out-

breaks. A special One Health questionnaire was developed to compile data from 235 heads

of household concerning their knowledge, attitudes, and practices with regard to controlling

RVF. Although the 2007 RVF outbreak in Sudan had negatively affected the participants’

food availability and livestock income, the participants did not fully understand how to identify

RVF symptoms and risk factors for both humans and livestock. For example, the participants

mistakenly believed that avoiding livestock that had suffered spontaneous abortions was the

least important risk factor for RVF. Although the majority noticed an increase in mosquito

population during the 2007 RVF outbreak, few used impregnated bed nets as preventive

measures. The community was reluctant to notify the authorities about RVF suspicion in live-

stock, a sentinel for human RVF infection. Almost all the respondents stressed that they

would not receive any compensation for their dead livestock if they notified the authorities. In

addition, the participants believed that controlling RVF outbreaks was mainly the responsibil-

ity of human health authorities rather than veterinary authorities. The majority of the partici-

pants were aware that RVF could spread from one region to another within the country.

Participants received most their information about RVF from social networks and the mass

media, rather than the health system or veterinarians. Because the perceived role of the com-

munity in controlling RVF was fragmented, the probability of RVF spread increased.

PLOS Neglected Tropical Diseases | DOI:10.1371/journal.pntd.0005383 February 16, 2017 1 / 12

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OPENACCESS

Citation: Hassan OA, Affognon H, Rocklov J,

Mburu P, Sang R, Ahlm C, et al. (2017) The One

Health approach to identify knowledge, attitudes

and practices that affect community involvement in

the control of Rift Valley fever outbreaks. PLoS

Negl Trop Dis 11(2): e0005383. doi:10.1371/

journal.pntd.0005383

Editor: Brian Bird, School of Veterinary Medicine

University of California Davis, UNITED STATES

Received: August 3, 2016

Accepted: February 3, 2017

Published: February 16, 2017

Copyright: © 2017 Hassan et al. This is an open

access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the paper and its Supporting Information

files.

Funding: The study was supported by the Swedish

International Development Cooperation Agency

and the Swedish Research Council. The first author

(OAH) was supported by a research scholarship

from Umeå Centre for Global Health Research, and

the Medical Faculty of Umeå University. The

funders had no role in study design, data collection

Author summary

Rift Valley fever (RVF), is a neglected, emerging, mosquito-borne disease that has caused

outbreaks in Africa and the Arabian Peninsula. RVF outbreaks have a severe negative

impact on livestock, human health and economy, placing further demands on communi-

ties already experiencing high levels of poverty. We believe there is an immediate need to

develop new approaches that will tackle the ongoing spread of RVF. One such approach

would prioritize outbreak prevention by involving local communities in the surveillance

of emerging zoonotic diseases, empowering local communities as agents of change rather

than relegating them as passive victims. RVF is a disease with global implication, but it

starts at a local level. Therefore, to control zoonotic disease such as RVF, it is important to

understand the local communities’ knowledge, attitudes and practices related to RVF.

Using a bottom-up perspective, we investigated the factors that keep the local community

from participating in the control of RVF outbreaks at the interface between humans, ani-

mals, and the environment. By devising acceptable and cost-effective interventions, we

believe local communities can be encouraged to be the first line of defense against RVF

outbreaks. Furthermore, policies aimed at curtailing RVF outbreaks would benefit from

involvement of the local communities.

Introduction

Global outbreak of zoonotic infections, not only affect human and animal health but also affect

food security, and socio-economic stability. To control such outbreaks require local as well

regional cooperation. Most zoonotic outbreaks begin and occur in settings where resources

are poor and where the outbreak severely affect the local community [1, 2]. These outbreaks

spread both within and outside the country of origin, often with devastating consequences [3].

Zoonotic infections originate and spread at the interface between humans, animals, and their

environments, making them candidates for the One Health approach to disease control [4–8].

Although international organizations, government authorities, and academic institutions,

believe the One Health concept should be a part of a local community’s response to zoonotic

infection, the One Health concept is rarely implemented at the community level. It is undeni-

able that community involvement is crucial in reducing the risk of zoonotic diseases at the

interface between animal-human and their ecosystem.

Rift Valley fever (RVF) is a mosquito-borne viral disease affecting both humans and ani-

mals. It can be transmitted by mosquito bites or by direct contact with infected animals, their

fluids, or products derived from them [9]. The disease in humans varies from a mild influ-

enza-like illness to more severe forms such as hemorrhagic fever, renal failure, encephalitis,

retinitis and miscarriage [9, 10]. Because there is no approved human vaccine or treatment

available for RVF, RVF poses a major threat to public health [9]. The infection causes so called

“abortion storm” in livestock and deadly epidemics in young animals, with severe conse-

quences for local and national economies [11]. RVF is present in Africa, and as of 2000, it has

spread to the Arabian Peninsula [12, 13]. Environmental changes, international travel, trade,

and the spread of RVF virus (RVFV) and vectors outside of Africa highlights the potential for

its global spread [14–17].

Sudan is an agricultural country with diverse ecology and has the second largest livestock

population in Africa. Most of the Sudanese population depends on livestock for food and

income. Our previous studies of the RVF 2007 outbreak in Sudan found a gap in knowledge

regarding the role of the local community [2, 18]. In this study, we used a bottom-up approach

Rift Valley fever outbreak control

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and analysis, decision to publish, or preparation of

the manuscript.

Competing interests: The authors have declared

that no competing interests exist.

to evaluate the knowledge, attitudes and practices that affect how the local agro-pastoralist

community in Sudan confronts an RVF outbreak.

Methods

Study area, population, and design

In accordance with the guidelines of strengthening and reporting of observational studies in

epidemiology (STROBE), a cross-sectional community-based study was conducted in March

2013 at the Mabroka Sagadi village in the Managil locality, Gezira State, Sudan (Fig 1).

The Managil locality is close to irrigation canals. The local people are mainly farmers and

shepherds and the locality is home to about 2 million livestock (mainly cattle, sheep and

goats). The annual rainfall in the region varies between 100 and 350 mm; however, in 2007 the

rain level reached up to 400 mm [19]. The rainy season is from mid-June to September. Mana-

gil is located in the Savannah zone and the temperature ranges from 25˚C to 46˚C.

The study area included all the states affected by the 2007 RVF outbreak (Fig 1). Most of the

reported human cases (n = 402) [20] were found in Gezira, so this state was selected. In Gezira,

the Managil locality reported the highest number of cases and the village of Mabroka Sagadi

had nine recorded human RVF cases during the 2007 outbreak. At the time of the study, there

were 5,830 inhabitants in Mabroka Sagadi village. Of the 641 households in the village, 240

households were randomly selected, with a response rate of 98% (n = 235). The household

head was defined as the person who in charge of the household and any dependents. We inter-

viewed the household heads and all of them were men or women at least 15 years of age.

Pilot study and validation of questionnaire

To develop the One Health questionnaire to collect data about RVF at the human-animal-envi-

ronment interfaces, we intensively searched the literature for information that would help us

develop questions regarding the disease and we searched for the best possible answers to these

questions supported by the medical literature. This research resulted in the One Health ques-

tionnaire that was designed to compile relevant data on RVF in humans, animals, and the envi-

ronment. Originally written in English, the questionnaire was eventually translated into Arabic

(S1 Table). The questions were open ended and the participants were allowed to provide more

than one answer. The participants’ answers were compared to the answers listed in the ques-

tionnaire but these answers were hidden from the participants to avoid leading questions. If the

participant’s answer was not in the listed answers, it was added to the category named “other”.

A two-day training workshop was held for data collectors (public health officers acquainted

with the study area) to discuss the objectives of the study, the contents of the questionnaire,

and the methods of the study.

A pilot study was conducted in the village of Algila (Fig 1). Algila had similar socio-cultural

and ecological characteristics to those of the final study area, and it was also affected by the

2007 RVF outbreak. The findings were analyzed and used to update the questionnaire for the

full-scale study.

Data collection and analysis

A pre-study field visit to the study area was conducted to build trust, explain the study objec-

tives, mobilize the community leaders, and ask the community to be involved in all parts of the

study. This led to a sense of ownership and empowerment. Thus, successful face-to- face inter-

views with the heads of households at their home could take place in a friendly environment.

Rift Valley fever outbreak control

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The thematic areas covered by the One Health questionnaire were socio-demographic con-

siderations, knowledge of RVF in animals and humans, attitudes and practices regarding RVF,

and environmental aspects of RVF (S1 Table).

The data were coded, entered into Microsoft Access, and checked for data entry errors by

re- entering 10% of the data from the questionnaires. The data were exported and analyzed

using STATA version 12 (Stata Corp LP. College Station, TX, USA).

Ethical statement

Ethical clearance was granted from the Ministry of Health, Gezira State, Sudan. All partici-

pants were informed about the objectives of the study and about the confidentiality of the

Fig 1. Map of Sudan. The states affected by Rift Valley fever in 2007 (Kassala, River Nile, Gezira, White Nile,

and Sennar) are indicated in yellow in the upper map. The pilot study area and the study area in Gezira State

are marked with triangles in the lower, expanded map.

doi:10.1371/journal.pntd.0005383.g001

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information and results. The participants signed an informed consent document for participa-

tion and they were free to leave the study at any time.

Results

Socio-demographic characteristics and the effect of RVF on the rural

economy

The study included slightly more women (53%) than men (47%), and almost 67% had a low

level of education (less than higher secondary school level) with no significant gender differ-

ence. Just over half (55%) were above 35 years of age, the vast majority (87%) of the heads of

households were married, and their household had at least six members (Table 1). Most

women were housewives, while men were mostly occupied with farming (Table 1).

Most of the households bred animals (72%) (Table 1). Cattle were most common, followed

by goats and sheep. Animals were kept at home (44%), near the home (22%), or far away from

home (6%). Around 25% of the households had members who worked as temporary herds-

men. Most of the households (71%) used their own livestock products as the main source of

food, and just under half (43%) sold livestock as a source of income. The 2007 RVF outbreak

negatively affected many households (46%), including disrupting the availability of food and

livestock trade for about 33% of the households.

RVF disease, transmission, protection, and sources of information

The awareness about RVF in general was high: 80% of the heads of households heard about

the disease. About 9% of the heads of households had seen people who had contracted RVF

during the 2007 outbreak. More than half of those interviewed stated that RVF is a zoonosis

that affects both animals and humans, and that RVF had been a serious health problem in the

area during the 2007 outbreak. The most common sources of information in the community

about an RVF outbreak was their social networks of relatives and friends (54%) and mass

media (23%); a less common source of information was the health system (6%) or others such

as veterinarians (5%).

Table 1. Socio-demographic characteristics of the study participants.

Category Subcategory Number (n = 235) %

Gender Male 111 47

Female 124 53

Age,years � 35 105 45

> 35 130 55

Educational Level* Low 158 67

High 77 33

Occupation** Housewife,Student,Unemployed 133 57

Farmer 55 23

Health professional/Teacher/Freelancer 47 20

Marital status Unmarried 31 13

Married 204 87

Breed animals Yes 170 72

No 65 28

*Low education is less than higher secondary school.

**The first group was lumped together during the analysis as they were all dependent in that context. The third group was lumped together during the

analysis as they were the most educated.

doi:10.1371/journal.pntd.0005383.t001

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According to the respondents, there was higher livestock mortality in the area during the

2007 RVF outbreak than the year before (2006) and the year after (2008) the outbreak. During

the 2007 RVF outbreak, 34% of the heads of households had experienced death of livestock; in

2006 and 2008 only 17% had experienced death of livestock. This difference, however, could

not be confirmed from official reports.

Although the community experienced higher livestock mortality, only some mentioned

known symptoms in livestock that died, such as nasal and ocular discharge and hemorrhagic

diarrhea (Table 2). Regarding sick livestock, known RVF symptoms were not mentioned by

the majority: only 20% stated hemorrhaging and less than 9% mentioned fever and refusal to

eat (Table 2). Likewise, RVF symptoms in humans were not well known to the majority of the

respondents: 25% stated that fever and hemorrhagic symptoms were most common.

Most of the respondents did not know how livestock become infected with RVF. For

human infection, (21%) stated that humans are infected through uncooked meat while 13%

suggested direct contact with livestock. Only a few respondents suggested other mode of trans-

mission such as raw milk (9%), and mosquito bites (6%). The most common answer on how

humans should avoid RVF, was to avoid uncooked meat and handling of sick livestock. Avoid-

ing livestock that had suffered miscarriage was the least important according to the results of

the survey.

Although few thought that RVF is a contagious disease, more than half of the respondents

expected to get RVF when it was present in their area―either due to animal-to-human contact

or human-to-human contact (Table 3). One-quarter said that they would avoid contact with

neighbors who they suspected of having RVF. About half of the participants (45%) were in

favor of patient isolation as a preventive measure during outbreaks and 12% stated that they

would avoid contact with RVF patients. Mosquito nets on beds were used by 60% of the

respondents, but less than half of these (40%) were impregnated. The majority (60%) had

noticed an increase in mosquito population during 2007. To prevent RVF in livestock, the

respondents suggested isolation of sick livestock (21%) and vaccination (14%). In addition, the

majority of respondents (73%) strongly recommended quarantine of RVF-infected livestock.

Table 2. Perceived RVF symptoms reported by participants regarding their livestock or livestock in

the area suspected of having RVF during the 2007 outbreak (n = 235).

Number of animals %

RVF symptoms perceived in animals with fatal disease

Nasal and ocular discharge 37 15

Do not remember 17 7

Diarrhea/hemorrhage 12 5

High fever 10 4

Abortion 10 4

RVF symptoms perceived in sick animals that survived

Hemorrhage 47 20

Do not remember 35 15

Fever 19 8

Stopped eating food 18 8

Other mixed symptoms 13 6

Digestive disorders 7 3

Note: More than one symptom was allowed.

doi:10.1371/journal.pntd.0005383.t002

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The survey revealed that two-thirds of the participants had a positive attitude about medical

treatment against RVF in humans. However, only one-third thought that medical treatment

could be used for livestock. They also indicated that veterinarians should diagnose RVF in live-

stock and health workers should diagnose RVF in human. Around 75% of the heads of house-

holds knew where to seek medical treatment, either in the public or the private health sector.

Reporting and control of an RVF outbreak

If an outbreak occurs, about 40% said they should notify the veterinary authorities about

the death of livestock. Almost all the respondents (99%) stressed that they would not get any

compensation for their dead livestock if they notified the authorities. When asked if any of

their own livestock had had RVF during the 2007 outbreak, 13% said yes. These suspected

cases were not confirmed by the authorities. When we asked which disciplines need to work

together in order to control RVF, only eight participants (3%) stated that veterinary and health

authorities should work together. The majority believed that human health authorities (50%)

rather than veterinary authorities (15%) should work to control RVF. With regard to the com-

munity’s role in confronting RVF, the respondents suggested that the community should

improve its hygienic measures (22%), its health education (18%) and its vector control (8%).

The majority of the study participants (70%) were aware that RVF could spread from one

region to another within the country. In addition, 66% of the participants revealed that they

were aware of the livestock trade ban associated with RVF outbreak inside and outside the

country.

Discussion

We used the 2007 RVF outbreak in Sudan as a case study to investigate, the knowledge, atti-

tudes and practices, from the One Health perspective that affect the involvement of the local

community in disrupting an emerging zoonotic infection. Most of the measures aimed to con-

trol RVF were formulated by authorities (i.e., health and veterinary) to be implemented by the

local communities (a top-down). For RVF, it seems as these actions are not enough as disease

emergence continues. We believed that insights from the local community (a bottom-up

approach) about RVF prevention and control could help stop the spread of RVF outbreaks.

This bottom-up approach could be a tool to better combat the transmission and the spread of

RVF in the regions where the outbreaks are initiated, and could enhance a top down approach.

To identify the important factors we used the unique One Health approach to gather informa-

tion about livestock, people, and the environment. We also investigated whether the commu-

nity considered the integration of the One Health approach of health, veterinarians, and

environment authorities as the best strategy to confront RVF and how they could contribute

to RVF control.

Table 3. Common perceived reasons as to how the participants could be infected by RVFV if spread in the area compared to what has been

reported in the literature.

Percieved reasons Number of Respondents(n = 235) % What has been reported in the literature

Person -to-person contact 94 40 Misconception by participants

We have animals 26 12 Possible if contact with sick animals

I am handling animals 11 5 Possible if animal is sick.

Get it through people coughing 5 2 Misconception by participants

Do not use mosquito bed net 3 1 Possible if bitten by an infected mosquito

Note: More than one answer was allowed.

doi:10.1371/journal.pntd.0005383.t003

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Although the community studied had experienced a large outbreak, few had proper knowl-

edge of RVF regarding cause, mode of transmission, symptoms, prevention, and control. This

lack of knowledge increases the chances of RVF spreading to neighboring areas and would

prevent the community from confronting the disease. The knowledge of risk factors for RVF

was insufficient, because the community only practiced some of the measures known to pre-

vent RVF [21] (e.g., eating cooked meat and staying away from sick livestock) while exposing

themselves to other risks (e.g., exposure to mosquitoes and handling miscarriage livestock). As

in most rural areas, these communities in rural Sudan depend on their livestock as a source of

food and income, and often breed and raise their livestock inside or near their homes [22].

The majority did not know that handling livestock that had miscarried was a serious risk factor

for RVF [23]. This lack of knowledge could pose a significant risk, especially for rural women,

as they tend to take care of livestock at home.

Although the community lives near irrigation canals, which serve as a breeding site for

mosquito vectors, the majority ignored mosquitoes as a source of infection. The lack of knowl-

edge of risk factors for transmission could explain the high number of cases reported in the

2007 RVF outbreak in Sudan [18]. Like other mosquito-borne diseases, RVF is associated with

heavy rains [23], so the authorities could update communities about rain forecasts. This

knowledge would encourage a participatory role of local communities in integrated vector

control management similar to the malaria control programs that have been established in

most countries where malaria is endemic. The infrastructure of such programs such as estab-

lished vector control management and the use of impregnated mosquitoes bed nets could also

help control other types of mosquito-borne viruses in endemic regions[24, 25].

Therefore, human behavior contributes to the disease emergence. To control the spread of

RVF, it is essential to understanding how local communities interact with livestock and the

environment. We expect that social scientists, who are well equipped to deal with human

behavior changes, will be able to find acceptable ways for rural communities to practice better

animal husbandry [26].

For control of RVF, we found the main focus in the community was human health and

access to regional hospitals, particularly in the rainy season when the roads are difficult to nav-

igate. Notably, the animal dimension to confronting a zoonosis such as RVF was not well

understood. To better implement the One Health approach, authorities could work together

with communities to prevent and control emerging zoonotic diseases. This is particularly

important because the veterinary services might not be able to cover a vast country like Sudan,

where the veterinarians are based in the capital of each locality. The veterinarians visit remote

villages for vaccination or investigation of suspected cases of abnormal livestock diseases and

visits during rainy season are very difficult due to flooded and otherwise impassable roads. In

such a context, voluntary animal health workers from the local communities could be trained

to identify livestock diseases, including RVF. This work would take place in collaboration

with veterinarians, who have an increasingly important role in global health [27]. Similarly,

human voluntary health workers could be trained to identify human diseases. These volunteers

could be selected in cooperation with community leaders, which would ensure successful

collaboration and communication between health care providers and the community. The

sustainability of such a system would depend on a rapid response and support from the

authorities when needed by the local communities. These suggestions are in keeping with a

participatory approach that regards farmers as being effective partners to curb zoonoses

[28, 29].

The rural household economy is affected by RVF outbreaks, regarding both food security

and disrupted incomes. There were two opposing interests. The community was only inter-

ested in interventions to curb the disease that would not result in the culling of livestock

Rift Valley fever outbreak control

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without compensation. The absence of a compensation system weakened the motivation to

report early cases in livestock to veterinary authority, a requirement if RVF is to be halted

before infecting humans. This lack of compensation could be a possible explanation for the

delay in reports of RVF in livestock. If RVF had been identified in livestock early, then live-

stock as well as human RVF outbreaks in Sudan in 2007 and in Kenya in 1997–1998 might

have been prevented [18, 30]. To support the devastated rural economy due to RVF outbreaks

[3], a new policy of compensation for culled or dead livestock must be developed. The respon-

dents stressed the importance of safe vaccination at the right time to prevent their livestock

from contracting RVF and preventing the spread of RVF to humans, [31]. Normally, RVF vac-

cination of livestock is not free in Sudan, an expenditure that might impede locals from regu-

larly vaccinating their livestock, bearing in mind that a new episode of RVF might take some

years to re-emerge. Therefore, subsidizing vaccinations for emerging zoonotic diseases might

encourage farmers to regularly vaccinate their livestock. In general, RVF livestock vaccines

are either inactivated or live attenuated [32, 33]. However, the inactivated vaccine needs multi-

ple doses to booster immunity, making it more expensive and more difficult to distribute.

Because the vaccine requires multiple shots, establishing immunity requires time and this vul-

nerability decreases the vaccine’s usefulness during outbreaks. The live attenuated vaccine is

administered as a single dose, but it has shown some teratogenic effects that can lead to abor-

tion among inoculated pregnant animals[34, 35]. However, safe vaccine remains the effective

way to protect animals and humans [33, 36].

The respondents were aware of the possibility of RVF spreading inside the country, espe-

cially through the free mobility livestock grazing system. They also knew about the economic

consequences of a ban on livestock trade after an RVF outbreak. This awareness is important

to consider when early warning systems are developed to avoid bias in disease surveillance.

The community’s main sources of information on RVF were social network and mass media

such as radio, not veterinarians or health workers, who were mainly involved in case notifica-

tion rather than increasing public awareness [37]. The strong dependence on social networks,

rather than on medical and veterinary professionals, could increase the risk of misconceptions

if the wrong information is spread. Thus, the World Health Organization recommends that

during zoonotic outbreaks interdisciplinary teams of health providers, veterinarians and en-

vironmentalists, provide main communication with the public [38]. These teams can com-

municate through social networks and mass media such as radio, which is one of the most

common sources of information in remote areas of many countries. This local involvement

will empower the community, allowing them to contribute to notification and control of the

outbreaks, and lead them to play proactive roles. This cooperation could strengthen the

national surveillance system, which depends mostly on passive notification, a system that

might overlook health related events in remote areas. Empowering livestock owners is an

opportunity to strengthen the surveillance system for zoonoses, including RVF [39].

Although our study was conducted in 2013 in an area that was affected during the 2007

RVF outbreak in Sudan, up-to-date questions about RVF were also asked at the time of the

study. For the questions related to the 2007 RVF outbreak, we considered recall bias. Since the

2007 RVF outbreak, no other recorded hemorrhagic fever outbreaks had occurred in this area

according to the participants, so the participants would not have mixed the information about

RVF with other similar diseases. In addition, the 2007 outbreak was severe, affecting humans,

livestock and the economy in a unique way, which made it easier to remember, decreasing the

possibility of recall bias.

In general, the results of this survey are generalizable for the agro-pastoralist regions of

Sudan due to the similarity of the context as well as for other countries that experience

endemic RVF with similar knowledge, attitudes and practices.

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Conclusions

This study addressed the challenges and opportunities of including local communities in con-

trolling RVF outbreaks at the interface between humans, animals, and their environment. The

suddenness of the outbreaks, the lack of treatment, the lack of vaccines, and the complex trans-

mission cycle of RVFV highlights the need to increase community participation in disrupting

RVF outbreaks. Crucial challenges include improving the knowledge and correcting miscon-

ceptions about RVF that result in risky behaviors. However, by empowering rural communi-

ties through education and motivating them to recognize cases early, the authorities could be

notified and could act accordingly to support the local community. The willingness of the

community to participate in curbing RVF outbreaks is an opportunity that can be effectively

managed in a bottom-up approach: the more we know about a community’s knowledge, atti-

tudes and practices related to the emergence of RVF, the better we will be embowering local

communities with the best information and strategies to prevent the spread of RVF. That is,

this bottom-up approach may result in mutually acceptable and cost-effective interventions

that can be used to disrupt transmission of RVF in affected communities.

Supporting information

S1 Checklist.

(DOC)

S1 Table. One Health questionnaire.

(DOCX)

Acknowledgments

We are grateful to the Ministry of Health, Gezira State, Sudan for facilitating the study. We

thank the community and the community leaders in the pilot and study areas for their kind

collaboration. We are also grateful to the data collectors. We also thank Dr. Rania Salah Eldin

Bashir Abass for kind help with Fig 1.

Author Contributions

Conceptualization: OAH CA JR HA RS ME.

Data curation: OAH PM.

Formal analysis: ME OAH.

Funding acquisition: ME.

Investigation: OAH.

Methodology: ME CA JR RS HA OAH.

Project administration: OAH ME.

Resources: OAH PM.

Writing – original draft: OAH PM HA JR RS CA ME.

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